Robotic Lung Transplantation

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Kenneth McCurry, MD:

Thank you very much for joining us on Cardiac Consult today. Today we're talking about some general information about lung transplantation and specifically about the sort of evolving and really new technique of robotic lung transplantation.

Greg, certainly I think you would agree that not everybody is appropriate for a robotic lung transplant, but maybe you could talk just a little bit about how robotic lung transplantation fits into the broader scheme of offering patients a lung transplantation.

Gregory Jones, MD:

I think with the traditional lung transplant incisions, they can be larger. They can occasionally go through the sternum or ribs, and that can cause pain, that can cause difficulty with chest wall mechanics and breathing. We obviously want to avoid that if at all possible. The robotic approach really gives us a minimally invasive approach to lung transplant, which until now wasn't really possible. Smaller incisions, no need to fracture ribs or to go through the sternum. Hopefully that translates to improved recovery, faster recovery, less pain and an easier time breathing in the postoperative period.

Kenneth McCurry, MD:

There have been many attempts, and I think many of us that have been involved in this field for a long time have done lung transplants minimally invasively in the appropriate patient. I will emphasize that some patients, either from a complexity standpoint – perhaps significant pulmonary hypertension, right ventricular dysfunction – or from an anatomical standpoint – small pleural space, adhesions, previous surgery – some patients are just not appropriate for a minimally invasive approach. But many people around the country have approached it through small mini thoracotomies, other sorts of things like that. But all of those approaches require spreading the ribs. Even though we can keep the incision somewhat small, not as small as Dr. Jones is able to do with robotic lung transplantation, but we still have to spread the ribs significantly. I think most people think that that's what causes a lot of the pain. With the robotic approach, there's very little or no rib spreading, correct?

Gregory Jones, MD:

Correct, yep. The robotic instruments go through ports, basically small incisions in between the ribs, but when they hinge, there is no rib spreading or pressing on the ribs. We're able to complete the operation using the camera and increase dexterity and some improvements in the surgical technique inside the patient without that rib spreading that would be required to kind of visualize the surgical field in the traditional minimally invasive transplant.

Kenneth McCurry, MD:

To be clear, so this is the same robotic platform that would be used for other types of thoracic surgery, cardiac surgery or even abdominal surgery?

Gregory Jones, MD:

Exactly. It's the same exact platform. I mean, it's made its way into all of the different surgical disciplines, I believe at this point. Same platform, same instruments and same leveraging of the technology.

Kenneth McCurry, MD:

So, we're really beginning to deploy what is already a well-developed technique in other surgical disciplines. Even in thoracic surgery, Dr. Jones does robotic lobectomies or even pneumonectomies on a weekly basis, but we're extrapolating that into the field of lung transplantation. We think it holds significant potential for advantage for our patient population.

Gregory Jones, MD:

Absolutely.

Kenneth McCurry, MD:

So just to be clear, Greg, you mentioned it a little bit ago, but what clinical or anatomical factors do you think would be most ideal for robotic lung transplantation?

Gregory Jones, MD:

We discussed this extensively when we were coming up with our protocol. There's just not a lot of centers that are doing it, so there's not a lot of numbers. It's basically a bit of a trial-and-error process, but we've looked at those that have gone before us, and we've come up with some anatomic parameters that we feel like are good indications for success in the robotic approach. The first centers on the chest cavity. We need a larger chest cavity in order to be able to work inside. Right now, we're using a total lung capacity over three liters as kind of a surrogate for chest wall size. We would prefer it to be a COPD patient because they tend to have larger chests, but some interstitial lung disease patients do have kind of preserved chest wall size. We're more looking at the total lung capacity as kind of a surrogate.

We will often use peripheral ECMO cannulation. They need to be able to have no anatomic contraindications to peripheral ECMO cannulation, VA-ECMO (venoarterial extracorporeal membrane oxygenation). We'll make sure that we have a CT scan that proves that. Then, other factors that play a role in terms of pathophysiology, we need to make sure that there's no or minimal pulmonary hypertension, no significant coronary artery disease, and we want normal biventricular function if possible.

Those who have had any prior chest procedures usually aren't candidates right now. We're excluding those patients. Any prior chest surgeries, even VAT (video-assisted thoracic) surgeries, those can cause significant scarring, more than you would expect. In those patients, it can be unsafe to use the robot.

Kenneth McCurry, MD:

As you stated, and maybe just extend it a little bit further, probably the ideal candidates would be COPD (chronic obstructive pulmonary disease) patients, IPF (idiopathic pulmonary fibrosis) patients or ILD (interstitial lung disease) patients whose chest is not too contracted, or CPFE patients, those patients with combined pulmonary fibrosis and emphysema. Those would be sort of the patient diseases that we would target for this approach.

Greg, maybe you could talk just a little bit about how the perioperative, postoperative anyway, management might be a little bit different for robotic lung transplantation.

Gregory Jones, MD:

Yeah. Intraoperative-wise, it takes a village, as we saw in our first one. I have to say thank you to all the teams that were involved because it felt like moving mountains to get there, and everybody really sprang into action. All the way from anesthesia, nursing, perfusion, the whole team really did a fantastic job of coming together, and the patient did really well as a result. But in terms of the postoperative period, what we were really excited to see was how quickly the patient recovered. He was on room air 24 hours after the surgery, no oxygen requirement whatsoever. Most astonishing to me was that when I saw him the next morning on rounds, I asked him what his pain level was, and he said it was a zero out of 10, which kind of exceeded my own expectations. That was really good to see.

He was out of the ICU within 48 hours to a regular bed on the floor, and he was out of the hospital within two weeks. That's definitely, certainly on the faster end of what we would expect for a lung transplant. I will say he was the ideal patient. He was in really good functional status coming in, which I think really helped his recovery, but we were very happy to see how the recovery process went.

I know that you and I discussed this before, just to kind of reiterate that the overall post-transplant care is the same in someone who's undergoing a traditional transplant. We don't change any medications. We don't change any of the pathways aside from it being a little bit more expedited, which we kind of make on a case-by-case basis. The treatment of the post-transplant patient is the same, which helps with consistency for the nursing teams and the providers upstairs.

Kenneth McCurry, MD:

Yeah. That's great. I know we talked about it a lot and our program has talked about it a lot, but how do you see things continuing here as we gain more experience?

Gregory Jones, MD:

I think that we will continue to get more facile. Right now, it's certainly longer than the traditional transplant. That takes some time to kind of get through the efficiencies of the process and continue to be doing single lung transplants with the robot. I'm hopeful that after a couple of single lung transplants and if things continue to go well, I'm hopeful that we can extend that to double lung transplants, again, for the appropriate patient. In terms of technology, we were able to use a really small incision, an impressively small incision, to get the old lung out and the new lung in with some leveraging of anatomy.

Kenneth McCurry, MD:

A little bit of a shoehorn there as I recall. A little bit of lube on the lung as well, perhaps.

Gregory Jones, MD:

But I think we have discussed other ways to approach the explant in the implant, such as incisions underneath the ribs, potentially through the diaphragm, that would basically be independent of the chest. That's an option. We have things to explore there. Then I think the technology of the robot will continue to improve, the dexterity, the 3D visualization. The newer robot now has tactile feedback, which was absent on the previous robot. There's some element of almost being like an open operation to be able to feel kind of tissue tension and things like that. Further down the road, there may be a space for a single incision robot to do something like this. That seems crazy to think about, and it seems far away, but I'm excited to see the prospect of that. If we're able to perform a lung transplant through one incision, that would be pretty remarkable.

Kenneth McCurry, MD:

Right around the corner.

Gregory Jones, MD:

That's right.

Kenneth McCurry, MD:

I think this is really exciting with many significant options that we hope will continue to benefit our patients. I think this is a dedicated interest, not only for our program, our lung transplant program here at Cleveland Clinic, but many other transplant programs here at Cleveland Clinic as well. We have a very active robotic kidney transplant program. The busiest robotic kidney transplant program in the country, and a very active robotic liver transplantation program as well. This is a dedicated focus with a lot of cross-fertilization between our programs, learning from each other so that we can do better for patients. That's generally the way that we approach things here.

Just to mention a few other things. We're a very experienced lung transplant program here at Cleveland Clinic. We're one of the busiest in the country on a year-to-year basis and have lots of other activities, lots of other research and clinical trials that are ongoing. We generally accept very high-risk and complex patients for lung transplantation. Indeed, about 20 to 25% of the patients that we transplant also undergo some other concomitant cardiac surgical procedures. We commonly do bypasses, coronary bypasses. We commonly do valve repairs, sometimes valve replacements as well. If there are patients out there that have been declined elsewhere due to complexity or difficulty, we're happy to consider those patients. Indeed, about 25 to 30% of the patients that we end up transplanting here at our center have been declined by at least one other lung transplant program in the United States. We also have a lot of other research activities.

We have a technique that we call EVLP (ex vivo lung perfusion) where we're able to take lungs and bring them back, put them on a machine, and perfuse them with some solutions over a number of hours so that we can get a better assessment of the lung function to make sure they're actually going to work well. We don't do that for every set of lungs that we transplant, but we do do it if there are any questions and we need to be sure that things are going to work well. We also see that platform in the future as an opportunity to be able to modify the organs. We're working on strategies where we can perfuse the lungs over a longer period of time, hours to a day or two or three. Then we could do things to modify the physiology of the organs and/or even the genetic makeup of the organ to improve outcomes in the recipient.

So, a lot of really interesting and futuristic things that we're engaged in here, and certainly robotic lung transplantation is at the forefront of those. We appreciate Greg's expertise around this and his leadership in this part of our program. If you have any questions at all regarding any patient issues, we're more than happy to entertain them. We want to thank you very much for listening to Cardiac Consult today.

Gregory Jones, MD:

Thank you.

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